Provider Demographics
NPI:1174774863
Name:X AWAITING INACTIVATION2
Entity type:Organization
Organization Name:X AWAITING INACTIVATION2
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DHA UBO
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:CONDON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:240-401-3643
Mailing Address - Street 1:301DUSTOFF AVE
Mailing Address - Street 2:LYSTER ARMY HEALTH CLINIC
Mailing Address - City:FORT RUCKER
Mailing Address - State:AL
Mailing Address - Zip Code:36362-5333
Mailing Address - Country:US
Mailing Address - Phone:334-255-7755
Mailing Address - Fax:334-255-7368
Practice Address - Street 1:301DUSTOFF AVE
Practice Address - Street 2:LYSTER ARMY HEALTH CLINIC
Practice Address - City:FORT RUCKER
Practice Address - State:AL
Practice Address - Zip Code:36362-5333
Practice Address - Country:US
Practice Address - Phone:334-255-7755
Practice Address - Fax:334-255-7368
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:X AWAITING INACTIVATION2
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-10-01
Last Update Date:2025-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALB1614161286500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes286500000XHospitalsMilitary Hospital